Saturday, May 19, 2012

A tag team of two contributors to Time Magazine's Battleland blog have misrepresented the facts concerning the possibility that Staff Sgt. Robert Bales may have been under the influence of the controversial antimalarial drug mefloquine (also known as Lariam) when he allegedly killed 17 men, women and children in two villages outside Kandahar last March.

Using false information; faulty interpretation of documents and innuendo; and in one case, withholding key disclosures regarding their background, these authors took a serious issue - the dangerous psychiatric and neurotoxic effects of mefloquine on some people and the history of the use of this drug by the military - and twisted it to further an agenda that just happened to match US interests in limiting speculation about the Kandahar massacre to Bales.

One of the two authors, Mark Benjamin, who years ago had written a number of articles on mefloquine's terrible side-effects, published his article on Bales and mefloquine at Huffington Post.

The other author, a former top Army psychiatrist, Elspeth Cameron Ritchie, has written three articles for Time's Battleland that have strongly suggested Bales' alleged crime was linked to mefloquine use. She recently also gave an interview on the topic to Nina Shapiro at Seattle Weekly.

Ritchie's background in certain aspects is not well known and certainly is surprising, given the mefloquine issue. Currently, she is chief clinical officer for the District of Columbia's Department of Mental Health. But back in 2002, she was Lieutenant Colonel Ritchie, program director for mental health policy for the assistant secretary of defense for health affairs and consultant on suicidal detainees at Guantanamo. Interestingly, this was at the same time all incoming detainees were forced to take large treatment doses of mefloquine, even as she likely had access to their medical records.

In addition, at an unspecified time between 2002 and 2007, she trained psychiatrists for Behavioral Science Consultation Teams (BSCT) that worked closely with Guantanamo interrogators. While the UN and numerous human rights groups have decried the use of health professionals in interrogations, Ritchie continues to defend the policy.

An "Emergency" Review of Mefloquine?

When it was first leaked that a single soldier, part of an Army Stryker Brigade, was in custody for the March 11 killings of up to 17 men, women and children in two villages near a counterinsurgency-inspired "Village Stability Platform" [VSP]), the horror of the massacre made it difficult to understand how the soldier - later identified as Staff Sgt. Robert Bales - could have done the killings.

Accordingly, a slew of news media reports focused on Bales' family life, his police record, his associates, the history of his duty postings and the possibility of his having post-traumatic stress disorder (PTSD), even while the Department of Defense (DoD) was quickly pulling off the Internet as many references to and pictures of Bales from military sources that it could. Meanwhile, reports were leaking out, including a major investigative piece by Australian SBS reporter Yalda Hakim, broadcast on March 28 atCNN, that a number of witnesses, including those in US custody, were saying there was more than one soldier present at the killings and perhaps as many as 20.

It is not surprising that some of the speculation surrounding the DoD's account of Bales as a lone shooter should focus upon what drugs he had been taking. One of the drugs discussed, mefloquine, is a controversial antimalarial drug known to have possible psychiatric and neurotoxic side effects. The first article proposing a Bales-mefloquine link appeared in the March 16 edition of Counterpunch.

But it wasn't until Benjamin's March 25 Huffington Post article that the mefloquine hypothesis took off in the press, leading to interviews for Benjamin at Democracy Now! and CNN. The reason for the heightened interest was Benjamin's contention that nine days after the killings, "a top-level Pentagon official ordered a widespread, emergency review" of how the drug was administered to troops. The implication was that a mefloquine-induced psychosis in Bales was possibly connected to the murders. [As described below, Benjamin's contention was later dropped, but the original version, including the quotes above, can be viewed at this linked web site.]

Yet, as a March 27 Truthout critique of Benjamin's article noted, there was no "widespread, emergency review" of mefloquine undertaken after the Kandahar killings, undermining the very premises of The Huffington Post piece. Benjamin had mistaken a March 20 "tasker" memo by a regional US medical command for the original order, which had been given by the assistant secretary of defense for health affairs (ASD-HA) back on January 17.

In his article, Benjamin quoted a March 20 Battleland post by Ritchie where she first raised the Bales-mefloquine link:

"'One obvious question to consider is whether he was on mefloquine (Lariam), an antimalarial medication,' Elspeth Cameron Ritchie wrote this week in TIME's "Battleland" blog, noting that the drug is still used in Afghanistan. "'This medication has been increasingly associated with neuropsychiatric side effects, including depression, psychosis and suicidal ideation.'"

In an email response to queries from Truthout, Benjamin would not comment upon any collaboration between himself and Ritchie. "My discussions with people who may or not be my sources will remain private."

Subsequently, Ritchie returned the favor to Benjamin, mentioning his Huffington Post article in an April 2 Battleland post. Ritchie asked "whether mefloquine or other toxic exposures - to licit or illicit drugs - might have been a contributing factor in the Afghan massacre."

Bales' attorney has picked up on the Benjamin-Ritchie mefloquine angle, telling CNN that he was interested in mefloquine as one of many possible drugs that might have affected his client's behavior.

Army Policy on Antimalarial Drugs

Bales was assigned to the Army's Third Stryker Brigade and, as such, his medical protocols fell under Central Command (CENTCOM) policy. According to CENTCOM rules, the antibiotic doxycycline, not mefloquine, is to be used for all malaria prophylaxis in Afghanistan, unless specifically medically contraindicated. This has been the case since, as Benjamin himself reported, the DoD in 2009 pulled back from use of Lariam except in special circumstances.

Moreover, according to CENTCOM orders, all departing soldiers are given "enough [antimalarial] medication for their deployment" when they leave the US. For soldiers deploying to Afghanistan, that medication has been overwhelmingly doxycycline, not mefloquine. There is no evidence that Bales was ever prescribed mefloquine, and while the Army's January review was prompted by known failures to prescribe the drug correctly, there is no evidence that this happened to Bales.

According to prescription figures provided to Truthout by DoD officials, mefloquine prescriptions have been declining for some time. In 2011, the Army gave out 169,690 scripts for doxycycline to 151,802 soldiers. (The DoD could not say if all of these were for malaria, or for other antibiotic use.) At the same time, only 1,780 soldiers (utilizing 1,921 scripts) were prescribed mefloquine, down approximately one-third from 2009 levels.

Bales' Stryker unit was part of I Corps stationed at Joint Base Lewis-McCord. In 2011, there were 6,566 scripts written for I Corps personnel and only 150 for mefloquine. On December 2, 2002, right around the time of Bales' actual deployment, the Army's policy changed again and mefloquine was downgraded from a second-line to a third-line malaria prophylactic drug. While none of the above proves Bales did or did not take mefloquine in Afghanistan, it makes the likelihood quite small.

[UPDATE 4/20 9:55 pm PST: The statistics for the number of DoD prescriptions of antimalarials were derived from the DOD Pharmaeconomic Center, which, as a DoD official explained to Truthout, "can pull data stateside because that reporting system exists." However, "this record of systems for visibility from Afghanistan (or Iraq) back to the states does not exist." Hence, there is no way to specifically say how many prescriptions of mefloquine (or any other antimalarial drug) was given inside Afghanistan. The official added, "within theater they certainly have visibility as to what is being dispensed and to who."

Yet, as explained in the article, as someone deployed from a stateside base to Afghanistan, Bales would have been prescribed enough antimalarial medication for his entire deployment before he left. Hence, assuming Bales correctly was prescribed doxycycline upon deployment, one would have to posit that Bales somehow lost his medication and then wrongly was prescribed mefloquine by some doctor in theater. There is no evidence or claim to date that this ever happened, though anecdotal reports have suggested that some events like this have occurred from time to time.]

Amplifying the problem with Benjamin and Ritchie's hypothesis concerning Bales and mefloquine is Ritchie's own contrasting history concerning mefloquine policy, some of it known and some of which can only be presumed or remain subject to speculation.

Ritchie, Guantanamo and Mefloquine

Ritchie had gone to Guantanamo, by her own account, four times. In October 2002, Ritchie indicated she first went to Guantanamo in order to "review all the suicidal gestures among the detainees." She said she "recommended many basic changes."

One can't say exactly how effective her recommendations were, in part because DoD figures concerning the number of suicide attempts and gestures by Guantanamo detainees has changed over the years and because the DoD labels some of the suicide gestures as attempts at "self-harm," but not suicide. But one damning report by BBC in 2005 noted that, in the year after Ritchie left, there were "350 incidents of self-harm, including 120 'hanging gestures."

In a 2003 New York Times article, a Guantanamo spokesman, Capt. Warren Neary, is quoted as saying that in the "18 months since the detention camp opened," there had been 28 suicide attempts by 18 individuals." "Most of those attempts" had been made in the first six months of 2003, that is, in the period just after, or even during, Ritchie's intervention on Guantanamo suicides.

As a physician, Ritchie likely reviewed the medical records for some or many of the detainees under her review. As previously reported at Truthout, the records would have shown that every detainee had been administered treatment doses of mefloquine upon arrival.

The treatment dose is a single 1,250 mg dose, versus the weekly 250 mg dose given for malaria prophylaxis, and what Bales would have taken (if he had taken mefloquine) upon arrival in Afghanistan.

Both treatment and prophylaxis dosages of mefloquine can cause serious side effects, according to medical reports. An April 16, 2002, meeting of the Interagency Working Group for Antimalarial Chemotherapy, which included DoD officials, the Working Group warned, "other treatment regimes should be carefully considered before mefloquine is used at the doses required for treatment." At this point, mefloquine had been given in treatment doses to all incoming detainees for three months and the policy would continue for years to come.

[UPDATE, May 19, 2012: The minutes of an Armed Forces Epidemiological Board Meeting on May 20, 2003 describes the presence of "Cameron Ritchie" at the IWG group meeting in January 2003. The speaker, Dr. Monica Parise, noted that the group specifically looked at the neuropsychiatric side effects of mefloquine. While the "serious reactions" were said to be "pretty rare," something along the order of "1 in 200 or so up to 1 in 10,000 of seizures or major psychiatric problems," she noted "there are a host of other more acute less severe neuropsychiatric issues that occur short-term, such as insomnia, strange dreams, fatigue, lack of energy, inability to concentrate, and some people have reported that those effects have lasted a very long time."

Parise continued (bold emphasis added): "I've heard cases that this has just ruined people's lives. I don't if anybody -- I had heard that there may be some data in DOD about how some of the studies that might shed light on that, but I've not seen anything in terms of effect on the brain. But I don't really think we have a good explanation of what that is. I mean, as I mentioned, at the meeting there was discussion -- and we did have a psychiatrist there -- of, well, are people susceptible, are they susceptible to these problems and this drug has brought that out?"

Presumably this psychiatrist was Dr. Ritchie.]

An Army physician who has published many journal articles on mefloquine called the mass presumptive treatment with mefloquine "pharmacological waterboarding."

Truthout's investigation determined that no US soldiers or contractors, even those brought from malarial-endemic regions by Halliburton subsidiary KBR, were administered presumptive doses of any anti-malaria drug, including mefloquine at Guantanamo.

Ritchie has never spoken out on the detainees' mefloquine dosing, which continued at least through 2005. She did not return a request for comment for this article.

Ritchie returned to Guantanamo in 2007 and/or 2008 to work in a forensic capacity on psychiatric evaluations of prisoners slated for trial by military commissions. In one high-profile evaluation, of Salim Hamden - whose case ultimately led to the Hamden v. Rumsfeld Supreme Court case in 2006, which threw out the first version of the military commissions as violations of the Uniform Code of Military Justice and the Geneva Conventions - Ritchie disagreed with the defense psychiatrist that Hamden, who had been tortured, suffered from PTSD and found him "manipulative."

In any case, Ritchie certainly would have looked at the medical records for the detainees she examined and could hardly have overlooked the presence of mefloquine. Given Ritchie's interest in suicide and her history of consulting on suicides at Guantanamo, one wonders if she were aware of the toxicology results for reported 2007 Guantanamo "suicide" Abdul Rahman Al Amri, which made special note of looking for mefloquine in his blood.

As reported by Truthout, the UN Special Rapporteur on extrajudicial, summary or arbitrary executions is looking into the Al Amri case, as well as that of 2009 reported suicide, Mohammad Al Hanashi.

Ritchie and the BSCTs

It is not known if Ritchie did more at Guantanamo, however, in an October 2008 article at Psychiatric News examining ongoing controversies over the use of psychiatrists in military interrogations at Guantanamo and elsewhere, Ritchie revealed she had taken a leading role in bringing psychiatrists onto the BSCTs. "The Army requires psychiatrists to complete a 136-hour course before taking part in interrogations," the article said. "Ritchie has taught parts of that program and said that four psychiatrists have attended it so far."

Ritchie may have taught the BSCTs when she worked in the Office of the Army Surgeon General (OASG) under Maj. Gen. Kevin Kiley. In 2006, a controversy arose when it was discovered that Kiley's office had continued to recommend the use of psychiatrists in interrogations, despite a policy statement from the American Psychiatric Association against use of doctors or psychiatrists in interrogations.

An October 20, 2006 OASG/MEDCOM policy memo issued by Kiley discussed BSCT training, including instruction in the "application" of "learned helplessness" "to the interrogation/debriefing processes."

"Learned helplessness" is a psychological syndrome so named by psychologist Martin Seligman, who was invited by the CIA to lecture on the topic at a Navy Survival, Evasion, Resistance and Escape school in May 2002. Both James Mitchell and Bruce Jessen have said they relied on the theory in their construction of a torture program for the CIA that same year.

An important 2007 article by Dr. Steven Miles in the American Journal of Bioethics looked closely at the experience of psychiatrists and psychologists working for the BSCT at Guantanamo. The article focused on the interrogation of Mohammad Al Qahtani in late 2002, an interrogation the Guantanamo military commissions convening authority admitted amounted to torture.

"Clinicians were integral to this abusive interrogation," Miles wrote.

In the 2008 Psychiatric News article, Ritchie defended the use of psychiatrists in interrogations, claiming, "Psychologists and psychiatrists are experts at enhancing rapport.... They also can counteract behavioral drift, the spiraling down of interrogation into a culture of coercion." Ritchie also defended the BSCT policy in an interview with NPR in September 2008. NPR said Ritchie contended "at the beginning of the war on terror, there was misunderstanding of 'what the rules were' for interrogations." Ritchie added, ""We don't try to defend (that)."

Ritchie has not changed her beliefs in these regards over the years. In the 2012 book "Women in Psychiatry: Personal Perspectives," Ritchie wrote, "Although controversial in the American Psychiatric Association and the media, I continue to believe that psychologists and forensic psychiatrists can contribute in a very positive way to legal, safe and effective interrogation."

A Mefloquine "Expert"

In January 2003, not long after she first went to Guantanamo, Ritchie, then working in the office of the assistant secretary of defense for health affairs, attended an "Experts Meeting" on malaria chemoprophylaxis organized by the Department of Health and Human Services and the Centers for Disease Control (CDC). A year later, in 2004, Ritchie, now "Psychiatry Consultant to the Army Surgeon General," gave a presentation to the DoD's Deployment Health Clinical Center on the "Neuropsychiatric Side-Effects of Mefloquine."

No published work by Ritchie could be found that referenced mefloquine or anti-malaria treatment or medication. Ritchie mentioned, as if in passing, her 2004 presentation in an April 4 article at Battleland two days after this author informed an anti-Lariam activist of its existence. In a very brief posting, Ritchie wrote, "There is a lot more in the literature since a 2004 talk I gave on the neuropsychiatric effects of the medication. There followed a flood of anecdotal information and articles in the media, but rigorous scientific literature was limited."

In fact, there were dozens, if not hundreds of studies and articles on mefloquine prior to her 2004 talk. Indeed, a 2004 review article on antimalarial drug toxicity in the journal Drug Safety listed dozens of peer-reviewed articles on mefloquine, its efficacy as a drug and its potential side effects. In the same year, the CDC issued guidelines indicating mefloquine should only be used when other standard drugs were not available, as it "associated with a higher rate of severe neuropsychiatric reactions when used at treatment doses."

In her April 4 article, Ritchie coyly did not indicate what the substance of her 2004 presentation was, nor what data she drew upon. For full disclosure sake, she should release her paper or notes pertaining to that presentation.

Why Push a Bales-Mefloquine Link?

Both Benjamin and Ritchie appear to have had an agenda: to make it appear far more probable than any facts would admit that Bales could have gone psychotic on mefloquine.

None of their articles ever considers that Bales may not have acted alone, or that indeed, is not proven to have killed anyone in those hamlets where 17 died. Most of all, their stories ignore problems with the DoD's narrative of events, with charges by Bales' attorney that the DoD has hidden evidence from his defense team, or, as this USA Today article notes, "blocked them from interviewing survivors and are withholding evidence of the March 11 attacks ..."

Key evidence that eyewitnesses to the attacks saw helicopters, men with walkie-talkies and upwards of 15 soldiers, as evidenced by this CNN interview and this Global Post article, is never mentioned by Ritchie or Benjamin.

Lacking such balanced reporting, it would seem the anti-torture journalist Benjamin and the former trainer for Guantanamo interrogation consultants have joined up to help promote the mainstream narrative of Bales as a single and possibly deranged killer. Together, they were quite successful in spreading the idea that Bales might have gone crazy from mefloquine.

Deranged Bales may have been, but whether his actions, if proven, were taken alone or as part of a larger US military or Special Forces operation that dark March night are matters for full investigation.

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About Me

I am a psychologist, living in Northern California. Over the years I have written about torture, national security, civil rights and other topics. Most of my stories, including major investigatory pieces, some co-written with Jason Leopold, have been published at Firedoglake, Truthout, and The Public Record.
A full backlog of my pre-Invictus writing, going back to May 2005, can be found at my Daily Kos page.
E-mail me at sfpsych at gmail dot com.

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This documentary, by award-winning producer Sherry Jones, details how the secret U.S. military interrogation program - "Survival, Evasion, Resistance and Escape" - or SERE - became the basis for many of the harshest methods used in interrogating prisoners in U.S custody.